Provider Demographics
NPI:1508885757
Name:DEMETRO, KEITH ROBERT
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:ROBERT
Last Name:DEMETRO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5354 NEW CASTLE RD
Mailing Address - Street 2:
Mailing Address - City:LOWELLVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44436-9532
Mailing Address - Country:US
Mailing Address - Phone:330-755-7090
Mailing Address - Fax:
Practice Address - Street 1:5354 NEW CASTLE RD
Practice Address - Street 2:
Practice Address - City:LOWELLVILLE
Practice Address - State:OH
Practice Address - Zip Code:44436
Practice Address - Country:US
Practice Address - Phone:330-755-7090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171WH0202X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0842888Medicaid
OH2059721Medicaid
OH0842888Medicaid
OH0842888Medicaid